Provider Demographics
NPI:1093713273
Name:WILSON, STEVEN M (OD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:M
Last Name:WILSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 STATE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-3620
Mailing Address - Country:US
Mailing Address - Phone:812-948-0616
Mailing Address - Fax:812-949-3447
Practice Address - Street 1:519 STATE ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-3620
Practice Address - Country:US
Practice Address - Phone:812-948-0616
Practice Address - Fax:812-949-3447
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0954DT152W00000X
IN18001984A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200038300Medicaid
KY1056447Medicaid
KY77340487Medicaid
KY000000042621OtherANTHEM
KY2433872000Medicaid
KY77340487Medicaid
IN200038300Medicaid
KY1056447Medicaid
KY00132004Medicare ID - Type Unspecified